Download Pervasive Developmental Disorders

REVIEW OF DEVELOPMENTAL PEDIATRICS
Maris D. Rosenberg, M.D.
Children’s Evaluation and Rehabilitation Center
Rose F. Kennedy UCEDD
Children’s Hospital at Montefiore
Part I: Know the milestones!
A baby is pulled to sit with no head lag, grasps a
rattle, and follows an object visually 180 degrees.
These milestones are typical for:
1. 2 months
2. 4 months
3. 6 months
4. 8 months
25%
25%
25%
25%
6
1
2
3
4
Tanya is now walking well, and can stoop to the
floor and get back up. She generally points to
indicate what she wants, but can ask for her
“bottle”, a “cookie” and her “blankie”. She
drinks from a sippy cup and feeds herself cheerios.
She places a toy bottle in her doll’s mouth. Tanya
is most likely a typically developing:
25%
25%
25%
25%
A.12 month old
B.15 month old
C.18 month old
D.24 month old
6
1
2
3
4
All of the following social-emotional
milestones emerge between 18 and 24
months of age EXCEPT:
1. Beginning defiant behaviors 25%
2. Imitation of behavior of
others
3. Development of interest in
other children
4. Playing social games like
“pat-a-cake”
25%
25%
25%
10
1
2
3
4
Of the following motor
milestones, the one that is
MOST typical of a 2 ½ year
old child is: 25% 25%
1.
2.
3.
4.
25%
25%
Walking up steps
Building a tower of 2 cubes
Scribbling
Imitating a vertical line
6
1
2
3
4
A 3 year old boy should have mastered
each of the following except:
25%
1.
2.
3.
4.
25%
25%
25%
Naming a red truck
Towering 6 cubes
Stating his name and gender
Hopping on one foot
6
1
2
3
4
On a pre-kindergarten screening a school
official is most concerned about a 5 year old
boy who cannot:
25%
1.
2.
3.
4.
25%
25%
25%
Draw a Person with 6 parts
Copy a Square
Name 4 colors
Tandem Walk
6
1
2
3
4
You would be most
concerned about:
1. A one year old who doesn’t 25%
stand alone
2. An 18 month old who cannot
walk backwards
3. A four year old who cannot
hop on each foot
4. A two year old who cannot
jump
25%
25%
25%
6
1
2
3
4
You would be less
concerned about:
25%
25%
25%
25%
1. A 3 year old who cannot answer a
“why” question
2. An 18 month old who uses 2
words
3. A one year old who doesn’t point
4. A 9 month old who doesn’t babble
6
1
2
3
4
The Individuals with Disabilities Education
Act (IDEA) requires states to provide:
20%
1.
2.
3.
4.
5.
20%
20%
20%
20%
Evaluations of “at risk” children ages 0-3
Services in the natural environment
Family-centered services to infants and toddlers
A “child-find” component
All of the above
6
1
2
3
4
5
ENTITLEMENTS
1975: PL 94-142, Education for All Handicapped Children Act: Free and
appropriate public education to all students with disabilites, ages 6-17
1986: PL 99-457, Part B (ages 3-5), Part H (ages 0-3)
1991: IDEA, Individuals with Disabilities Education Act
PART C: “Early Intervention”
– Birth to age 3
– Child Find
– Evaluation and therapeutic services for children with
developmental delays
– Evaluation and follow-up of “at risk” children
– Multidisciplinary coordinated interagency model
– IFSP: family is central focus of service
– Services to be provided in “natural environment”
• IDEA- Part B (to age 21)
• Provides special services for children whose
disabilities severely affect their educational
performance
– specific LD, serious emotional disturbance, other
health impaired…
– Individual Educational Plan (IEP)
– Least restrictive environment
• Section 504 of Vocational Rehabilitation Act of
1973: Provides accommodations for students with a
physical or mental impairment that substantially limits
one or more major life activity
PART 2: Know the Presentation of
Developmental Disorders, and their
differential diagnoses
• Infant/toddlers with motor delay
• Toddler/preschoolers with language delay
• School age children with school failure
You are evaluating a 9 month old baby who
is not yet sitting without support. She is a
former 26 week premature infant. Brain
MRI reveals periventricular leukomalacia.
Of the following findings, which would you
most likely expect to see:
1.
2.
3.
4.
5.
Increased tone in all 4 extremities, UE>LE
20%
Equally increased tone in all 4 extremities
Dyskinetic, choreoathetoid movements
Increased tone in all 4 extremities, LE>UE
Increased tone in the right upper extremities
compared with the left
20%
20%
20%
20%
6
1
2
3
4
5
Motor Delay in Infancy
Rule out:
• Neurological Disorders
• Genetic Disorders
• Metabolic Disorders
• Systemic Illness
Cerebral Palsy
• Disorder of Movement and Posture
• Results from a nonprogressive brain injury or
developmental deficit of brain
• Injury occurs during the period of brain growth
• Diagnosis of exclusion
• Associated with conditions reflecting CNS insult:
MR, Seizures, Sensory Deficits
• Classified by type
– Spastic: most common: sub-classified by
distribution
– Dyskinetic, Hypotonic, Mixed
Selected Clinical Findings or Laboratory
Abnormalities Suggesting a Metabolic Disorder
Curry CJ et al. Am J Med Genet. 1997
Failure of appropriate growth
Arachnodactyly
Recurrent unexplained illness
Hepatosplenomegaly
Seizures
Metabolic/lactic acidosis
Ataxia
Hyperuricemia
Loss of psychomotor skills
Hyperammonemia
Hypotonia
Low cholesterol
“Coarse” appearance
Structural hair abnormalities
Eye abnormalities (cataracts,
ophthalmoplegia, corneal clousding,
abnormal retina)
Bone abnormalities (dysostosis, occipital
horns, punctuate calcifications)
Recurrent somnolence/coma
Skin abnormalities (angiokeratoma,
“orange-peel” skin, ichthyosis)
Abnormal sexual differentiation
??Parents of a 3 year old girl present with
concerns about speech and language delays.
Their daughter has a vocabulary of about 10
words, and she recently began pointing to body
parts and following single un-gestured
commands. She can imitate a vertical line,
jump in place, and broad jump. She is able to
wash and dry her hands, and put on a t-shirt.
In your office, she points to your stethoscope,
and when you hand it to her she smiles at you
and places it on her father’s chest.
??You most strongly suspect:
A. Mental Retardation
B. Autistic Spectrum Disorder
C. Mixed receptive/repressive language disorder
D. Hearing Impairment
E. Environmental understimulation
??Your first referral is to:
A. Social service
B. Audiology
C. Psychology
D. Speech and Language Pathology
??You most strongly suspect:
A. Mental Retardation
B. Autistic Spectrum Disorder
C. Mixed receptive/repressive language disorder
D. Hearing Impairment
E. Environmental understimulation
??Your first referral is to:
A. Social service
B. Audiology
C. Psychology
D. Speech and Language Pathology
Language Delay in a
Toddler/Preschooler
CONSIDER:
• Hearing Impairment
• Global Developmental Delay:
Intellectual Disability
• Communication Disorders
• Pervasive Developmental Disorders
• Environmental Factors
• General Health
Language Delay in a
Toddler/Preschooler
CONSIDER:
• Hearing Impairment
•
•
•
•
•
Global Developmental Delay: Intellectual Disability
Communication Disorders
Pervasive Developmental Disorders
Environmental Factors
General Health
HEARING IMPAIRMENT:
Key Points
• 1-6/1000 newborns
• 50% genetic
30% syndromic (e.g. Waardenburg, Pendred,
Usher)
70% non-syndromic, (e.g. connexin 26/GJB2)
-77% AR, 22%AD, 1% X-linked or mitoch.
• 50% Non-genetic:
TORCH infection
Ear/craniofacial anomalies
Birth Weight<1500 g.
Low Apgar Scores (0-3 at 5 min, 0-6 at 10 min)
Respiratory Distress/ Prolonged mechanical
ventilation, hyperbilirubinemia requiring exchg
transfusion
Bacterial meningitis/ Ototoxic meds
HEARING LOSS:
Post-newborn
• Recurrent or persistent OME (at least 3 mo)
• Head trauma with fracture of temporal bone
• Congenital CMV (often asymptomatic, hl may show up in later
• Childhood infectious
childhood- median age 44 months)
diseases (eg, meningitis, mumps,
measles)
• Chemotherapy
• Structural anomalies: (e.g. Mondini malformation,
enlarged vestibular aqueduct)
disorders (eg, Hunter syndrome),
• Neurodegenerative
demyelinating diseases (eg,Friedreich ataxia, CharcotMarie- Tooth )
Hearing Loss
Mild
25-39
Moderate 40-68
Severe
70-94
dBHL
Tools for Hearing Screening
 Auditory Brainstem Response (ABR), Evoked
Otoacoustic Emissions (OAE)
 Tests of Auditory Pathway Structural Integrity
 Newborn Screening
 Visual Reinforcement Audiometry (VRA)
 9-12 months+
 Play Audiometry
 2-4 years+
 Conventional Audiometry
 4 years +
Visual Impairment
• Overall prevalence: 12.2 per 1,000 under age 18
• Severe Visual Impairment: .06 per 1,000
– legally blind: less than 20/200 vision in the better eye or a very
limited field of vision (20 degrees at its widest point)
– or totally blind
• The effect of visual problems on a child's development depends on
severity, type of loss, age of loss, and overall level of the child’s
functioning
• Lack of visual input limits imitation and exposure to non-verbal cues
affecting social skill development ; milestones in all areas can be
delayed
» NICHCY
P.O. Box 1492
Washington, DC 20013
??A 5 year old boy presents for health
maintenance. Developmental surveillance
reveals that he can copy a circle, knows the
adjectives “tired” and “hungry” and can
broad jump, but cannot hop in place, draw a
person in 3 parts or name 4 colors. You
suspect:
A. Learning Disability
B. Mild Intellectual Disability (Mental Retardation)
C. Cerebral palsy
D. Autistic Spectrum Disorder
E. Severe Intellectual Disability
??A 5 year old boy presents for health
maintenance. Developmental surveillance
reveals that he can copy a circle, knows the
adjectives “tired” and “hungry” and can
broad jump, but cannot hop in place, draw a
person in 3 parts or name 4 colors. You
suspect:
A. Learning Disability
B. Mild Intellectual Disability (Mental Retardation)
C. Cerebral palsy
D. Autistic Spectrum Disorder
E. Severe Intellectual Disability
Language Delay in a
Preschooler
CONSIDER:
• Hearing Impairment
• Global Developmental Delay:
Intellectual Disability (Mental Retardation)
•
•
•
•
Communication Disorders
Pervasive Developmental Disorders
Environmental Factors
General Health
INTELLECTUAL DISABILITY
(Mental Retardation)
2010 definition (AAIDD):
Disability characterized by:
•
•
•
Significant limitations in intellectual
functioning (IQ >2SD below mean)
Significant limitations in adaptive behavior
(covers many everyday social and practical
skills)
Originates before age 18
What’s in a name?
• “Intellectual Disability”: eligibility for
federal programs (IDEA, SSI, medicaid
waiver)
• “Mental Retardation”: citizenship, legal
status, civil and criminal justice, early care
and education, health care, training and
employment
Mild ID/MR: IQ level 50-55 to approx. 70
Moderate ID/MR: IQ level 35-40 to 50-55
Severe ID/MR: IQ level 20-25 to 35-40
Profound ID/MR: IQ level below 20 or 25
ID Level Predicts Rate of Learning and Ultimate
Prognosis**
• Mild ID/MR:
Reads at grade 3-6 level, lives independently, holds
job, has children
• Moderate ID/MR:
Reads at 1st to 3rd grade level, community living,
supportive work environment
• Severe ID/MR:
Some sight words (“stop”, “exit”), needs
supervision/assistance in ADL
**In absence of significant behavioral disturbance
Intellectual Disability-Key Points
• Assessment:
– Standardized psychological testingIQ
• IQ=developmental age /chronological age
– Test of adaptive functioning, e.g. Vineland Adaptive
Behavior Scales
• Earlier presentation= more severe degree
– Moderate to Severe : Presents infancy to age 2
– Mild : Presents preschool to early school age
• 2-3% of population, majority mild ID/MR
ID/MR- Etiology
• Prenatal (50-70%) : genetic, CNS
malformations, fetal compromise,
infection, teratogens
• Perinatal (<10%): HIE, prematurity
• Postnatal: Trauma, asphyxia, infection,
toxins,vascular malformations, tumors,
degenerative disease
• Environmental(additive):Deprivation/malnutrition
• More severe forms, more likely to find definitive
etiology
ID/MR: Associated Conditions
•
•
•
•
Behavior Disorders
Seizures
Motor Impairments/CP
Syndromes and their associated
medical conditions
• More common with more severe
intellectual disability
??A stranger should be able to understand
half of a child’s speech at age:
A. 12 months
B. 18 months
C. 24 months
D. 36 months
??A stranger should be able to understand
half of a child’s speech at age:
A. 12 months
B. 18 months
C. 24 months
D. 36 months
Language Delay in a
Preschooler
CONSIDER:
• Hearing Impairment
• Global Developmental Delay: Intellectual Disability
• Communication Disorders
• Pervasive Developmental Disorders
• Environmental Factors
• General Health
Communication Disorders
• Expressive Language Disorders
• Mixed Expressive/Receptive
Disorders
• Phonological Disorders
• Expressive Disorders
Disorders of morphology (form), semantics (word meaning),
syntax (grammar), pragmatics (social use of language)
• Mixed Expressive/Receptive Disorders:
– Above plus comprehension deficits
• Phonological Disorders
– Disorders of articulation (motor movements), dyspraxias
(motor planning)
– Disorders of fluency (flow,rhythm)
– Disorders of voice/resonance
Communication Disorders- Key
Points
• 3-5% of Preschoolers
– Estimated 30-50% go on to develop reading disorders
• Genetic Basis: May be seen in 30-40% of first
degree relatives
• Developmental Language Disorder alone vs.
communication deficit associated with:
–
–
–
–
Cognitive delay
PDD
Hearing impairments
Social/environmental factors
“Stuttering”
• Disturbance in fluency and time patterning of
speech
• Begins age 2 ½ to 4, peak age 5
• Male:female 3-4: 1
• 75% of preschoolers will stop
• Indications for evaluation:
– Family history of stuttering
– Persists 6 months or more
– Presence of concomitant speech or language
disorders
– Secondary emotional distress
?? All of the following observations are
considered risk factors for Autistic
Spectrum Disorders except:
A. Lack of protodeclarative pointing at
16 months
B. Lack of babbling at one year
C. Lack of gaze monitoring at 10
months
D. Echoing phrases at 18 months
?? All of the following observations are
considered risk factors for Autistic
Spectrum Disorders except:
A. Lack of protodeclarative pointing at
16 months
B. Lack of babbling at one year
C. Lack of gaze monitoring at 10
months
D. Echoing phrases at 18 months
Language Delay in a
Toddler/Preschooler
CONSIDER:
• Hearing Impairment
• Global Developmental Delay: Intellectual Disability
• Communication Disorders
• Pervasive Developmental
( “Autistic Spectrum”) Disorders
• Environmental Factors
• General Health
Pervasive Developmental
Disorders- DSM IV
• Autistic Disorder
• PDD NOS
• Asperger’s Disorder
• Rett’s Syndrome
• Childhood Disintegrative Disorder
AUTISTIC DISORDER*
1. QUALITATIVE IMPAIRMENT IN SOCIAL
INTERACTION
a) marked impairment in nonverbal
behaviors (eye contact, facial expressions, gestures)
b) failure to develop peer relationships
c) lack of spontaneous seeking to share
enjoyment, interests, or achievements with
other people
d) lack of social or emotional reciprocity
*[Six or more criteria, at least two from (1),one each
from (2) and (3)]
2. QUALITATIVE IMPAIRMENT IN
COMMUNICATION
(a) delay in, or total lack of, the development
of spoken language
(b) marked impairment in the ability to initiate
or sustain a conversation
(c) stereotyped and repetitive use of
language or idiosyncratic language
(d) lack of varied, spontaneous make-believe
play or social imitative play appropriate to
developmental level
3. RESTRICTED REPETITIVE AND
STEREOTYPED PATTERNS OF
BEHAVIORS, INTERESTS AND ACTIVITIES
(a) encompassing preoccupation with
stereotyped and restricted patterns of interest
(b) inflexible adherence to specific,
nonfunctional routines or rituals
(c) stereotyped and repetitive motor
mannerisms
(d) persistent preoccupation with parts of
objects
Autistic Spectrum Disorders
Key Points
• Prevalence( Pediatrics 2009:124): ~ 1/100
• Male: Female 4:1
• Seen in association with :
–
–
–
–
Seizure disorders, congenital infection, metabolic abn (PKU)
Neurocutaneous disorders (TS, NF)
Genetic Disorders (Fra X, Angelman’s, Smith-Lemli Opitz )
No proven ass’n with vaccines (MMR, thimerosol)
• Genetic Basis: concordance in monozygotic (6080%) vs. dizygotic twins, sibs (3-7%)
Autistic Disorder
• Presents prior to age 3 with:
Absent or delayed joint attention
Lack of:
– gaze monitoring (8-10 mos),
– proto-imperative pointing(12-14 mos),
– proto-declarative pointing(14-16 mos)
• Delayed language
• Delayed play skills
• Language regression between 12-24
months in 1/3 of cases
PDD NOS
• Presentations that do not meet criteria for autism
– late age of onset
– atypical symptomatology
– subthreshold symptomatology
• Autistic Spectrum Disorders
– Clinical presentation varies with degree of
severity and cognitive level
Asperger’s Disorder
•
•
Qualitative impairment in social interaction
No clinically significant general delay in
language
–
–
•
Impaired pragmatics
“Little professors”
No clinically significant delay in cognitive
development or in the development of ageappropriate self-help skills
–
Motor coordination difficulties
• Childhood Disintegrative Disorder
– Normal development first 2 years
– Loss of previously acquired skills by age 10
• Rett’s Syndrome
–
–
–
–
–
Occurs in females
Normal development first 5 months
Deceleration in head growth between 5-48 m.
Stereotypic hand movements
Impaired communication, socialization; severe
MR
– MECP2 mutation
Autism Screening Instruments:
e.g. CHAT, m-CHAT
Diagnostic Instruments:
e.g. CARS, ADOS, ADIR
ASD’s: Treatment
• Special Education
– ABA, TEACCH, DIR
• Psychopharmacology for targeted behaviors
– Hyperactivity, aggression, self-injury
• CAM considered by a majority of families
– Antifungals, IVIG, megavitamins, chelation,
hyperbaric oxygen, secretin, gluten or casein-free
diets
– Few are evidence-based
?? An 8 year old second grade boy was referred
for evaluation due to academic difficulties. His
psychological and psychoeducational
evaluations revealed:
WISC 4: Full Scale IQ= 99, Verbal Comprehension =85, Perceptual
Reasoning= 105, working memory= 110, Processing Speed= 108;
WIAT 2: Word Reading= 92, Reading comprehension =81, Numerical
operations =98, Math reasoning =79.
This child’s likely diagnosis is:
A. Borderline Intellectual Functioning
B. Reading Disability
C. Attention Deficit Hyperactivity Disorder
D. Nonverbal Learning Disability
?? An 8 year old second grade boy was referred
for evaluation due to academic difficulties. His
psychological and psychoeducational
evaluations revealed:
WISC 4: Full Scale IQ= 99, Verbal Comprehension =85, Perceptual
Reasoning= 105, working memory= 110, Processing Speed= 108;
WIAT 2: Word Reading= 92, Reading comprehension =81, Numerical
operations =98, Math reasoning =79.
This child’s likely diagnosis is:
A. Borderline Intellectual Functioning
B. Reading Disability
C. Attention Deficit Hyperactivity Disorder
D. Nonverbal Learning Disability
School Failure
• “Slow Learner”: Borderline Intelligence
• Learning Disorders: Average Intelligence
• Attention Deficit and Disruptive Behavior
Disorders
Oppositional Defiant Disorder, Conduct Disorder
• Mood and Anxiety Disorders
• Chronic Medical Illness
• Psychosocial stressors
Learning Disabilities: Key Points
• Discrepancy between intellectual potential and
achievement
• Associated Self-esteem and Behavioral Issues
• “Dyslexia”=Reading Disability
– Majority= Language-based, disordered phonemic
processing
– Familial: Up to 60% of parents also have reading
difficulties, 68% concordance in monozygotic
twins, 38% in dizygotic
– Structural and functional CNS abnormalities
• 50% Of Children with Reading Disability meet criteria
for ADHD
Learning Disabilities: Evaluation
• Cognitive Assessment
• Full scale IQ, Verbal IQ, Performance IQ
– 2 SD discrepancy is significant
– PIQ>VIQ: Language-based LD: difficulties in
phonemic processing, reading, spelling
– VIQ>PIQ: Nonverbal LD: perceptual problems,
motor impairments, slow processing speed,
dyscalculia
• Educational (achievement) testing
•
-Specific academic abilities
?? A 9 year old third grade boy is brought to your office by
his mother who is distraught about his report card. He is
below average in reading and spelling and his teacher
states that he does not complete assignments and is
distractible in class. He is not a management problem at
home other than when it’s time to do his homework. He
has friends and excels on the baseball field. An
appropriate next step would be:
A. Request completion of parent and teacher Vanderbilt
Questionnaires
B. Initiate a trial of methylphenidate
C. Order psychological and psychoeducational testing
D. Refer to Child Psychiatry
?? A 9 year old third grade boy is brought to your office by
his mother who is distraught about his report card. He is
below average in reading and spelling and his teacher
states that he does not complete assignments and is
distractible in class. He is not a management problem at
home other than when it’s time to do his homework. He
has friends and excels on the baseball field. An
appropriate next step would be:
A. Request completion of parent and teacher Vanderbilt
Questionnaires
B. Initiate a trial of methylphenidate
C. Order psychological and psychoeducational testing
D. Refer to Child Psychiatry
Attention-Deficit/Hyperactivity Disorder
• A. Symptoms of Inattention, Impulsivity,
Hyperactivity
• B. Some symptoms present before age 7
years.
• C. Impairment from the symptoms is present
in two or more settings
• D. Clear evidence of clinically significant
impairment in social, academic, or
occupational functioning.
Attention-Deficit/Hyperactivity Disorder:
Inattention, Hyperactivity/Impulsivity
• INATTENTION:
Six (or more) for at least 6 months: often
•
(a) does not attend to details, makes careless mistakes
(b) has difficulty sustaining attention in tasks or play
(c) does not listen when spoken to directly
(d) does not follow through on instructions
(e) has difficulty with organization
(f) avoids tasks that require sustained mental effort
(g) loses things
(h) easily distracted
(i) forgetful
• HYPERACTIVITY/IMPULSIVITY :
• Six (or more) for at least 6 months: often
(a) fidgets with hands or feet or squirms in seat
(b) leaves seat when remaining seated is expected
(c) runs about or climbs excessively (in adolescents or
adults, feelings of restlessness)
(d) has difficulty playing or engaging in leisure activities
quietly
(e) "on the go" or acts as if "driven by a motor“
(f) talks excessively
(g) blurts out answers before questions have been
completed
(h) has difficulty awaiting turn
(i) interrupts or intrudes on others
• ADHD Subtypes:
Combined Type (80%*)
Predominantly Inattentive Type (10-15%*)
Predominantly Hyperactive-Impulsive Type (5%*)
*in school-age children
ADHD: Key Points
• Disorder of dopamine and norepinephrine
systems in frontostriatal circuitry
• 3-7% of school age children
• Male: female (6:1-3:1)
• Genetic Predisposition: 5-6 fold increase in
first degree relatives
• Environmental Factors: e.g. head trauma,
lead exposure, VLBW, prenatal teratogens
• Symptoms Persist into Adulthood in 60-80%
ADHD- Key Points cont’d
 Symptoms in two or more settings
 Rating scales
 Consider co-morbid conditions
 Rule out Medical Conditions (e.g.thyroid disorder,
toxic exposure, medications, CNS disease)
ADHD- Key points
(cont’d)
• Co-morbid Conditions:
– Learning Disorders
– Anxiety Disorders
– Oppositional Defiant Disorder
– Conduct Disorder
– Tic Disorders
– Mood Disorders
– Substance abuse disorders (adolescents)
ADHD- Treatment
• Psychopharmacologic: stimulants= first line
– Inhibit reuptake of dopamine and
norepinephrine
– Stimulant Side effects: appetite suppression,
headache, abdominal pain, growth
suppression, irritability, onset/ exacerbation
of tics
– “Black box” warnings
• Behavioral Interventions
MTA Study
(Pediatrics 113:754-761, 2004):
Behavior Therapy alone not as effective
as medication alone
597 children ages 7-9.9 at 6 centers,
treated for 14 months
– 68% improved with combination of
medication and intensive behavioral
treatment
– 56% improved with medication alone
– 34% improved with behavioral treatment
alone
Medications for ADHD
Brand Name
STIMULANTS
Methylphenidateshort-acting
Ritalin
Intermediate-acting Metadate ER, Methylin ER
long-acting
Concerta, Ritalin LA, Metadate CD
transdermal
Daytrana
Dexmethylphenidate
Focalin
Dextroamphetamine sulfateshort- acting
Dexedrine
Intermediate-acting
Lisdexamfetamine
long-acting
Mixed amphetamines
Long-acting
Dexedrine spansules
Vyvanase
Adderall
Adderall XR
NOREPINEPHRINE REUTAKE
INHIBITOR
Atomoxetine
Brand Name
Strattera
ALPHA 2 AGONISTS
Clonidine
Catapres
Guanfacine
Tenex
• ?? A distraught mother phones you asking for advice. She met with
her 9 year old son’s teacher who states that your patient Johnny does
not listen, talks back, and recently has been physically lashing out at
other children. He is in jeopardy of repeating the 4th grade. Mother
wonders whether a trial of “that medication my nephew takes that
starts with an r” would be helpful. You conclude:
A. Johnny’s behavior is most consistent with the lack of impulse control
associated with ADHD.
B. Johnny’s behavior is likely to meet criteria for a disorder often co-morbid
with ADHD, but not consistent with ADHD alone.
C. Johnny is also likely to be cruel to animals, to steal and to run away from
home.
D. Johnny’s behavior is consistent with the general class of “internalizing”
behaviors.
• ?? A distraught mother phones you asking for advice. She met with
her 9 year old son’s teacher who states that your patient Johnny
does not listen, talks back, and recently has been physically lashing
out at other children. He is in jeopardy of repeating the 4th grade.
Mother wonders whether a trial of “that medication my nephew
takes that starts with an r” would be helpful. You conclude:
A. Johnny’s behavior is most consistent with the lack of impulse control
associated with ADHD.
B. Johnny’s behavior is likely to meet criteria for a disorder often comorbid with ADHD, but not consistent with ADHD alone.
C. Johnny is also likely to be cruel to animals, to steal and to run away from
home.
D. Johnny’s behavior is consistent with the general class of “internalizing”
behaviors.
“Externalizing Disorders”
• ADHD
• Oppositional-Defiant Disorder
• Conduct Disorder
Oppositional Defiant Disorder
•
•
•
•
•
•
•
•
•
•
Actively does not follow adults' requests
Angry and resentful of others
Argues with adults
Blames others for own mistakes
Has few or no friends or has lost friends
Is in constant trouble in school
Loses temper
Spiteful or seeks revenge
Touchy or easily annoyed
Disturbance causes clinically significant impairment in social,
academic or occupational functioning,
• Behaviors do not occur exclusively during the course of a Psychotic or
Mood Disorder
• Criteria are not met for Conduct Disorder
Conduct Disorder
•
•
•
•
•
•
•
•
•
Antisocial behaviors, such as bullying and fighting
Breaking rules without apparent reason
Cruel or aggressive behavior toward people and animals
Destruction of property
Heavy drinking and/or heavy illicit drug use
Deceitfulness or theft
Running away
Truancy (beginning before age 13)
Disturbance causes clinically significant impairment in social,
academic or occupational functioning,
• Childhood Onset type: onset of at least one criterion prior to age 10
• Adolescent Onset type: absence of any criteria prior to age 10
?? The mother of your 14 year old patient, Rachel, confides in you that
her daughter has changed. Now finishing 8th grade, Rachel tends to
come home from school, get into bed and turn on the television most
every day. Over a year ago she quit the Field Hockey team and the
Key Club, activities she enjoyed in middle school stating she “wasn’t
good enough”. Previously an A-/B+ student, she now has a B-/C
average. When her mother offers her help with her schoolwork,
Rachel snaps at her and states; “I get nervous during tests but I
understand the work.” Her physical examination is normal although
you note a significant increase in her BMI in the past year. You are
concerned that Rachel might be exhibiting symptoms of:
A. Major Depression
B. Generalized Anxiety Disorder
C. School Phobia
D. Dysthymic Disorder
?? The mother of your 14 year old patient, Rachel, confides in you
that her daughter has changed. Now finishing 8th grade, Rachel
tends to come home from school, get into bed and turn on the
television most every day. Over a year ago she quit the Field
Hockey team and the Key Club, activities she enjoyed in middle
school stating she “wasn’t good enough”. Previously an A-/B+
student, she now has a B-/C average. When her mother offers her
help with her schoolwork, Rachel snaps at her and states: “I get
nervous during tests but I understand the work.” Her physical
examination is normal although you note a significant increase in
her BMI in the past year. You are concerned that Rachel might be
exhibiting symptoms of:
A. Major Depression
B. Generalized Anxiety Disorder
C. School Phobia
D. Dysthymic Disorder
“Internalizing Disorders”
Mood Disorders: e.g. Major Depressive
Disorder, Dysthymic Disorder, Bipolar
Disorder
Anxiety Disorders: e.g. Generalized Anxiety
Disorder, Separation Anxiety Disorder,
Panic Disorder, Social Anxiety Disorder,
School Phobia, Obsessive-Compulsive
Disorder, Post-traumatic Stress Disorder
Major Depressive Disorder
• Five or more of the following (nearly every day):
–
–
–
–
–
–
–
–
–
Depressed more most of the day
Diminished interest or pleasure
Significant weight loss or gain
Insomnia or hypersomnia
Psychomotor retardation
Fatique or loss of energy
Feelings of worthlessness or excessive guilt
Diminished ability to think or concentrate/indecisiveness
Recurrent thoughts of death/suicidal ideation
– Symptoms do not meet criteria for a mixed episode, they cause
significant distress or impairment in social, occupational or other
important areas of functioning, and are not due to substance
abuse, not better accounted for by bereavement.
Dysthymic Disorder
– Depressed mood for most of the day, for more days
than not, for at least two years. In children and
adolescents, mood can be irritable and duration
must be at least one year.
– Presence of two or more:
•
•
•
•
•
•
Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatique
Low self-esteem
Poor concentration
Feelings of hopelessness
• Person has not been without the symptoms for at
least 2 months at a time
Generalized Anxiety Disorder
• Excessive anxiety and worry, occurring more days than not
for at least 6 months, about a number of events or activities.
Worry is difficult to control, and is associated with 3 or
more of the following
•
•
•
•
•
•
•
Restlessness or feeling keyed up or on the edge
Easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance
Disturbance is not due to specific features of other anxiety
disorders, causes significant distress or impairment in functioning,
not due to direct physiological effects of a substance or general
medical condition.
In Summary……
• 1. Know developmental milestones!
• 2. Know how developmental/behavioral disorders
present.
• 3. Know the differential diagnoses of developmental
delays and behavior disorders:
-Etiologies of motor delays
-Intellectual Disabilities
-Language Disorders
-Autistic Spectrum Disorders
-Learning Disabilities
-Internalizing Disorders
-Externalizing Disorders
Good Luck!!!